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Page 5 of 5 <br />Division records indicate the following permittee contact information. If this information is not current, please type or <br />print current contact information: <br />Permittee Contact: <br />ThomasJ. Musch <br />Permittee Company: <br />Wa6WOMOWO <br />--rhbmxsJ ►�vc <br />Address: <br />514 Americas Way, PMB 3773 <br />Box Elder, SD57719-7600 <br />Phone Number: <br />(720) 878-2597 <br />Fax Number: <br />Email Address: <br />Vmusch@rocketmail.com <br />I, the undersigned, hereby state that the information provided in this report is true and accurate, and that site operations are <br />being co}3ducted in accordance with the Division approved mining and reclamation plans. <br />Signature <br />M -AF -02 <br />Owner, or Documented Designee <br />Uq-15 <br />Date <br />